Study reveals inadequate investigations into baby deaths

13 June 2016

A report published this month has found that local investigations into cases of stillbirths, early neonatal deaths and severe brain injuries occurring as a result of incidents during term labour are falling far short of required standards.

The report, published by The Royal College of Obstetricians and Gynaecologists (RCOG), is the first annual report in the Each Baby Counts initiative. Looking at the cases of 921 babies born across the UK in 2015 who were either stillborn during term labour, or who suffered early neonatal deaths or severe brain injuries, the report found several areas where local investigations are lacking. The key findings are:

27 per cent of investigations were classified as poor quality

Of those that passed initial quality checks, 39 per cent contained no actions to improve care

96 per cent of reviews were made up of multi-disciplinary teams – however only 62 per cent contained a neonatologist

Caroline Davey, Chief Executive of Bliss, the premature and sick baby charity said: "Every baby who is stillborn, who dies soon after birth, or who experiences severe brain injury, following an incident during term labour, represents a tragedy for each family affected. It is therefore particularly alarming that such high numbers of investigations into these cases were of a poor standard.

"This report clearly highlights that more needs to be done to ensure that neonatologists are involved in multi-disciplinary teams conducting investigations, and that parents should also be included in this process to truly understand where improvements can be made in the care of babies to prevent avoidable harm in future."

Each Baby Counts is a national quality improvement programme, launched in October 2014, aiming to halve the number of these tragic events by 2020. This project will bring together the lessons learned from a review of all local investigations in order to improve the quality of care in labour across the UK.